Saturday, January 31, 2015

If you are not familiar with Representative Tim Murphy's legislation to overhaul America's broken mental health system, this post isn't for you. The legislation died when congress convened, but Rep. Murphy is planning to reintroduce the legislation to this congress, and he has 115 co-sponsors for the bill. In the last session, APA took no stance on the bill; they wrote a letter supporting the idea of legislative change and said they looked forward to working with Murphy on this. Rep. Murphy has said that the new legislation to be proposed will have some changes, changes that APA finds more in alignment with member concerns, such as an effort to increase the mental health workforce (I believe through tele-psychiatry) and to increase the emphasis on parity. The bills requirement that every state have an outpatient civil commitment program may include funding to other types of treatment such as mental health courts, and I'm not aware of any changes to the idea that HIPAA privacy rights to patients will be modified such that mental health professionals will be permitted to communicate with caretakers of people with severe mental illnesses if it's felt to be necessary for the patient's safety or welfare. While the text of the bill has not been released yet, the APA has come out in support of the soon-to-be proposed legislation.

I was disappointed to see that APA supported this, and I'm planning to write an article on it. If you're a psychiatrist and an APA member, I'd love to hear your thoughts and possibly quote you. Feel free to comment here, or to contact me at shrinkrapblog at g mail dot com. And as always, everyone's thoughts are welcome.

Monday, January 26, 2015

I often hear people talk about how we have to keep guns away from the mentally ill. A judge friend recently said it quite bluntly, "What's the issue with guns and the mentally ill? They shouldn't have them." A cousin posted a link to a story about a man who killed his family and then himself. Cousin commented, "We have to find a way to keep guns from the mentally ill." The article mentioned nothing about a history of mental disorder or psychiatric treatment or distress in the man who killed his family and himself; people were shocked, there was no clear motive, the gun was owned legally. Granted, by the time you kill your family and yourself, there may well be a mental illness leading you to this, but people say "Keep guns from the mentally ill" as though they wear signs indicating who they are. Sometimes, the first clear indicator that mental illness is present is an act of violence, often a suicide attempt or worse, a completed suicide. It's all awful.

So I thought I would help here with some guidelines as to how to identify those with mental illness so we actually can do a good job of getting their guns. Here would be my criteria for labeling people so that we could prevent mass murders and other atrocities:

~Anyone who has a been civilly committed to a hospital for a suicidal or violent act.~Anyone who has been civilly committed for threatening such things/ saying them/ or thinking them.~Anyone who has been voluntarily in a psychiatric unit, even if not acutely dangerous right now, there is clearly a mental disorder present.~Anyone who has seen a psychiatrist or therapist. To get reimbursed for these services, you need a DSM code to submit, so all these folks are mentally ill.~Anyone on Social Security Disability for a psychiatric reason. ~Anyone who has gotten a psychotropic medication from a primary care provider, a psychiatric NP, or any other prescriber. Purchase of any psychotropic medication should immediately trigger notification of the FBI. Remember, some anti-convulsants are prescribed for psychiatric reasons, so prescriptions will need to show clear indications for the medications. The pharmacists will have a dedicated line.~Anyone who has taken a sleeping pill, because sleep problems are often secondary to other psychiatric conditions, plus they slow reaction times and can cause cognitive issues. We don't think people under the influence of sleep medications should be operating guns, do we? ~Anyone who purchases over-the-counter sleep medications, or any medication that can induce drowsiness. If you need to be drugged with something that warns against operating heavy machinery, the FBI needs to know and you don't need to be pointing a gun at anyone. Plus, do we really want people who are sleep deprived to be handling guns? They can be very cranky. ~For the same reason, anyone who takes narcotics for pain, coughs, or recreation. Or amphetamines for that matter -- they make people jumpier, not a good mix with a gun. And testosterone makes people more aggressive, so that should be a no-no. Need a mood supplement: St. Johns Wort or SAM-e? The government needs to know. ~Anyone who tells a health professional about mood changes, feeling sad or stressed. This could be a warning sign that a mood disorder is present and you never know when someone might swing to being a killer. ~Because many people with mental illness never seek treatment, we need a list of psychiatric symptoms to be made public, and all teachers and employers should be required to report when they hear of, or observe, any of these symptoms. Voices, paranoia, moodiness, irritability, anxiety? There should be mandatory reporting with stiff criminal sentences for any health care provider, teacher, coach, or employer who does not report the name of anyone with psychiatric symptoms to a federal gun database.~Google searches should be monitored for those looking up mental disorders or psychiatric symptoms. Facebook/Twitter/Instagram posts should also have identified phrases that are associated with mental illness. Those teens who post song lyrics about existential angst or the end of the world -- the government needs to know. ~Substance abuse is a mental illness, and guns and alcohol/drugs don't mix. They are a recipe for disaster. Liquor stores should have a threshold amount for purchases, along with requisite questionnaires to determine who is drinking too much. Case of beer for the Superbowl? List the names and addresses of who those who will be sharing with you and the predicted number of beers/person. Unused portions along with accountability charts need to be returned so those who over-imbibe can be identified.The government needs to know. ~Reclusive and weird: absolutely no gun. The government needs to know about anyone who isn't out of their house by 9 AM on weekdays. Special dispensations could be issued for people who work at home or have unusual hours, provided they do leave their house for enough hours/week and have a threshold number of social contacts.

So if you look at it this way, it becomes pretty easy to identify the mentally ill. You target treatment settings, medications used for their treatment, and observed or stated symptoms of psychiatric symptoms. We still will miss a few people, but if we can identify these folks, and keep guns out of their hands, I guarantee the rate of gun violence will go down. It's a sure fire thing. (Of note: Satire alert)

Wednesday, January 14, 2015

I have one thing to say about Mark Lukach's essay, "My lovely wife on the psych ward." That one thing is: Read it! It's beautiful. Mr. Lukach does a masterful job of describing his feelings as he plows through two months' long episodes of psychosis with his wonderful wife. When a friend gives him a copy of R.D. Laing's The Divided Self: An Existential Study in Sanity and Madness, Mr. Lukach learns about the world of anti-psychiatry and psychiatric survivors. He struggles through with wanting to be a good husband, to help his wife get better, but he questions whether what he is doing is right, and he stumbles through with his own guilt. And when his wife gets better, they struggle with the bitter aftertaste of what it meant to be her caretaker, to be in control. The story isn't all pretty, but the writing and the description of the conflicts is beautifully done.

Yet Laing ripped through a conception I had of myself that I held dear:
that I was a good husband. Laing died in 1989, more than 20 years before
I picked up his book, so who knows what he really would have thought.
His ideas about mental health and its treatment could have shifted with
the times. But in my admittedly sensitive state, I felt Laing saying:
Patients are good. Doctors are bad. Family members botch things up by
listening to physicians and becoming bumbling accomplices in the crime
of psychiatry. And I was an accessory, conspiring to force Giulia to
take medication against her will that made her distant, unhappy, and
slow, and that silenced her psychotic thoughts. That same medication
enabled Giulia to remain alive, so everything else was secondary, as far
as I was concerned. I never doubted the rightness of my motives. From
the beginning, I’d cast myself in the role of Giulia’s self-effacing
caregiver—not a saint, but definitely a guy working on the side of good.
Laing made me feel like I was her tormentor.

Thursday, January 08, 2015

You may have noticed that I don't write on Shrink Rap as often as I used to. Somewhere in there, I got busy with our book, and I also started to use Twitter more. Instead of a real post, I thought I would put up a sample of things I've been Tweeting.

Saturday, January 03, 2015

It's half-time and the Ravens are beating the Steelers by one point. I thought I'd take this opportunity to tell you about my latest obsession. I spoke to Clink this morning. I happened to mention that I was frustrated: among other things, my Jawbone wasn't registering right; I'd have to reload. Now Clink and Roy run circles around me when it comes to technology, but here, I had Clink. "This is something technologic, right? It's not a medical emergency?" She may have offered to send an ambulance (or maybe I'm just making that up because it sounds good), but no, my choppers are fine and there's no problem at all with ingestion. So, followed by a few too many cookies over the holidays. And some bagels, pizza, holiday meals, and too much everything, on New Year's Eve, I went to the store and bought a fitness tracker. I got the Up Move, by Jawbone. I don't even know what that means, or why someone would call a company Jawbone --it sounds very unfriendly and very aggressive -- but it was the cheapest one and it got decent reviews, and I figured less was probably better. I want some inspiration to move more and eat less, and I don't care what my heart rate is when I'm swimming without Bluetooth.

It says I should take 10,000 steps a day. I'm trying. It's a lot of steps. I've done it 3 days in a row, and I'm definitely moving more -- it seems to take about 1 hour and 40 minutes of purposeful, non-strenuous motion. The dog is very happy -- he loves walks. We've done four trips around the block just to try to add steps. The trick is that this is over the holiday week and I'm not working. When life returns to normal on Monday, all bets are off, and I'll settle for moving a little more and eating a little less, without having to push for 10,000 each day. For the moment, however, I'm enjoying my latest obsession. No ambulance necessary.

Above: Kobe relaxing after 7,823 steps. Can you guess which team he's rooting for?

Friday, January 02, 2015

As you may be aware, we are in the process of doing research for a book called Committed: The Battle Over Forced Psychiatric Care. Our plan is to include a chapter on guns and mental illness, and I'm interested in talking to gun owners who believe they are suffering with mental health issues, but won't seek care because they are worried this will impact their right to own firearms. I'm well aware that gun owners often say they'd never see a therapist, or never take psychiatric medications, but what one does for a theoretical problem may well be different then what one does while they are actually suffering. So if you'd be willing to share your story of how you are avoiding treatment, or worked your way around your concerns, I'd love to hear from you, either in the comment section of this post, or by direct email to shrinkrapblog at gmail dot com. Obviously, real names won't be used in a manuscript. And, as always, thank you for visiting Shrink Rap today and for sending this post to anyone you know who might be interested in participating. ----ADDENDUM: I'll take any interesting story about the intersection of guns and mental health. Must be in the US, but from a patient, a doctor, a family member, someone afraid to get care, someone who did get care and had a happy or unhappy outcome...Just a guns and mental health story that's a little more involved then 'my shrink asked me to lock my gun away and I did.'